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Trying to conceive can be a stressful process for many women, especially those who may be experiencing difficulty resulting from infertility. Patients who achieve pregnancy but then experience a pregnancy loss may feel even more frustrated. Recurrent pregnancy loss is defined as having two or more pregnancy losses following a documented gestational sac in the uterus.  Causes of recurrent loss can be related to uterine anomalies, immune issues, chromosomal imbalances in either the male or female partner, hormone issues, and most common, chromosomal imbalances in the embryo. 

Uterine Anomalies:

One of the most common uterine anomalies contributing to recurrent pregnancy loss is called a uterine septum.   A uterine septum results from failure of the uterus to develop normally in a female fetus in utero.  A septum acts like a dividing wall in the middle of the uterine cavity. . The septum itself is composed of fibrous tissue that does not have much blood supply on its own. Therefore, if a fertilized egg implants on the septum, it may not receive adequate nutrients during the pregnancy resulting in the possibility of loss. Most physicians agree that a uterine septum increases the risk of a pregnancy loss and should be removed if found. 

Fibroids, or benign fibrous tissue  of the uterus, are another anomaly responsible for some pregnancy loss or difficulty conceiving. There are different types of fibroids, depending on their location within the uterus. Fibroids located within the uterine cavity where the embryo implants and grows are linked to pregnancy loss.  There is also an increased risk for miscarriage in women with very large fibroids. 

Fortunately, treatment for both uterine septum and fibroids within the uterine cavity is available. Both can be removed surgically through minor, outpatient surgery in a minimally invasive procedure called Hysteroscopy.  Sometimes a larger procedure called a Myomectomy is needed for the removal of larger fibroids. 

Immune issues:  

Immune issues can involve either overactivity or low activity. With overactivity, the body responds by attacking and damaging its own tissues. In low activity cases, the body has difficulty fighting off infections and is, therefore, more vulnerable to disease. Two conditions seen in patients with recurrent pregnancy loss that fall under immune causes are Antiphospholipid syndrome and 

Antiphospholipid syndrome,  is an immune disorder where the body makes antibodies that attack phospholipids. Phospholipids are major components of plasma membranes and the structural component of cells. In antiphospholipid syndrome, blood clots can form within arteries, veins, and other organs. Recurrent pregnancy loss or stillbirth may be an effect of aPL as the clots may affect normal placental function. . 

This disorder is believed to be genetic and rare, found to be present in less than 200,000 cases each year. Medical professionals can prescribe blood-thinning medications to reduce the risk of blood clots.

Inherited thrombophilias is an inherited DNA mutation which results in the body producing too much or too little of a blood-clotting protein. The relationship between inherited thrombophilias and pregnancy loss remains controversial amongst doctors. They have reported evidence suggests treatment with an anticoagulant does not improve pregnancy outcomes. 

Hormone issues:

While there are several examples of hormone disruptions that could affect infertility and pregnancy loss, some examples are abnormal thyroid levels, elevated prolactin, and polycystic ovary syndrome (PCOS).

Abnormal thyroid function, both hyperthyroid and hypothyroid, appear to correlate to pregnancy loss. Hyperthyroidism produces too much thyroid hormone and can cause body processes to speed up, as in an elevated heart rate and metabolism.

On the other hand, hypothyroidism is the effect of too little or no thyroid hormone being produced. Most of the time thyroid conditions may be treated with medications. 

 

Prolactin is a hormone secreted after childbirth which aids in breastmilk production. In some cases, elevated prolactin in a woman before pregnancy may lead to infertility and or pregnancy loss as hormone production affects the estrogen and progesterone levels. However, high levels of prolactin may signal hypothyroidism or pituitary tumors and should be examined further. Sometimes there is no cause for the elevated levels of prolactin, and it may be treated with medication. 

Hypothyroidism is usually managed with medications, and tumors may be removed surgically. Other causes of elevated prolactin may be medications or stress. 

PCOS is common within the United States, with over 200,000 diagnosed cases each year. There is some evidence that women with PCOS have higher rates of pregnancy loss. This may be due to elevated male hormones, and elevated insulin levels. 

One resolution may be maintaining stable blood sugar levels. Some medical professionals might prescribe medications such as Metformin. Diet is another method that can manage PCOS symptoms and may help reduce pregnancy loss.

Hyperglycemia

Insulin resistance is similar to hormone issues listed above. When the body does not respond to insulin, glucose cannot be absorbed from the blood. The result can be prediabetes or diabetes.  There is currently evidence demonstrating that elevated blood glucose can be associated with increase first-trimester loss [R]. 

Within my clinic, I often screen patients with a fasting blood glucose test as well as screenings for insulin levels and HgbA1C. The results will provide a snapshot of what blood glucose has looked like over a 3-month period. 

Diet and lifestyle changes are usually recommended; however, medications such as Metformin may also be prescribed.

Chromosomal imbalances 

Balanced Translocation refers to a condition in which part of the chromosome has broken off and reattached to another location. Depending on the circumstances, a chromosomal translocation may be harmless, or it may cause serious health problems. 

In the case of balanced, or reciprocal, translocation many individuals are unaware they are affected until pregnancy. If an affected person’s cells attempt to divide to create egg or sperm cells, the irregular chromosome would contain extra or missing genetic material. It could lead to pregnancy loss, depending on the gene affected. 

The translocation can be diagnosed through a test called a karyotype; however, there is no treatment. 

Chromosomal abnormalities of the embryo account for the most common cause of first-trimester pregnancy loss. Unfortunately, there is no simple test, such as a blood draw, to determine the cause. Genetic testing after a pregnancy loss can be performed if pregnancy tissue can be collected and sent to the lab.  Pregnancy tissue can be collected in cases where a woman miscarries at home or if the patient has a procedure called a Dilatation and Curettage ( D&C ) .  If available the pregnancy can be tested genetically to confirm the presence of an abnormal number of chromosomes. 

If you’d like support with pregnancy loss, or you are experiencing difficulty conceiving , contact us and we can help you get tested and decide if treatment is right for you. 

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